When a Catholic health care network took over a community hospital here
in 1995, the resulting clash over whether the hospital could continue providing
sterilization and contraceptive services to its poor patients led to intense
negotiations between the Catholic system, the city and the community.

The unusual solution: the creation of a
hospital-within-a-hospital, run by the city and located on the
buildings fifth floor, which will provide the services forbidden by
ethical directives from the U.S. bishops.

Austins solution may be unusual, but the dilemma is not. In the
face of rising health care costs, many city- and county-based public hospitals
across the United States have faced the decision to close or merge. Often,
these local tax-supported hospitals have merged with a nearby hospital
sustained by a large, national Catholic health care system.

From 1990 through 2001, there were 171 such mergers of non-Catholic with
Catholic hospitals, according to a 2002 report by Catholics for a Free Choice.
While welcoming the survival of hospital services in their community, many
non-Catholics express concerns that their own beliefs will not be respected in
the Catholic facility if they request reproductive services that the U.S.
bishops Ethical and Religious Directives for Catholic Health Care
Services do not allow.

Since 1884, Austins public hospital, Brackenridge, treated
patients regardless of ability to pay. But in a state where one in five people
has no health coverage, leaving public and charity hospitals to assume most of
the resulting cost, the burden became too great for Brackenridge -- a crushing
$38 million debt. Austins solution in 1995 was to lease Brackenridge and
the adjacent Childrens Hospital to the Catholic Seton Healthcare
Network.

Seton Healthcare Network, which last year celebrated its own century of
service in Austin, is part of Ascension Health, the nations largest
not-for-profit health network, a merger of the Daughters of Charity National
Health System based in St. Louis and the Sisters of St. Joseph Health System in
Ann Arbor, Mich.

But trouble of one sort -- financial -- was succeeded by trouble of
another sort -- ethical. Brackenridge had provided sterilization and
contraceptive services as an option for its 134,666 patients treated
annually.

Seton Healthcare could not provide those services. The initial solution
reached by Seton and the city of Austin in 1995 was a wall of
separation -- meaning that Seton staff didnt provide proscribed
services, city staff did. However, it was deemed inadequate in 2001 by the U.S.
bishops, who were being prodded by the Vatican, which in turn was being fed
alarmist material by local right-wing Catholics.

The city began months of solution-seeking negotiations with Seton, plus
a coalition of community groups that included Planned Parenthood, the Religious
Coalition for Reproductive Choice, Consumers Union, the Texas Womens
Political Caucus, the League of Women Voters, the National Council of Jewish
Women, the Gray Panthers, the National Organization for Women, the American
Civil Liberties Union, and the Texas Abortion and Reproductive Rights Action
League.

'What we were trying to do
was let Seton remain Catholic and let us do the things we need to do in
dealing with a public hospital.' -- Betty Dunkerley

In 2002, Seton and the city reached a second agreement: The city would
take back the fifth floor of Brackenridge Hospital and construct its own
hospital within a hospital for services Seton would not provide.
The unit is to open this month.

A good solution? Given the parameters our community gave us, I
think it was a good one, said Betty Dunkerley, who was the principal
negotiator for the city of Austin.

-- Photo by Suzanne Batchelor

'The people in the
community are of diverse religions and beliefs, and to have one belief
imposed on their health care is unfortunate and unfair.' -- Peggy
Romberg

However, Peggy Romberg, who headed the coalition of community groups in
the negotiations, said the city didnt fight hard enough for
straightforward access to disputed services. The people in the community
are of diverse religions and beliefs, and to have one belief imposed on their
health care is unfortunate and unfair, she said.

-- Photo by Suzanne Batchelor

'People talk about the
directives as if it's a book about sterilization. It's a book about the
ministry of Jesus in health care.' -- Patricia Hayes

In addition to Dunkerley and Romberg, other principal negotiators for
the convoluted, hard-won decision were Patricia Hayes for Seton Healthcare
Network, and Frances Kissling of national group Catholics for a Free
Choice.

According to Dunkerley, then assistant city manager, Brackenridge was in
debt because it served the region but did not receive regional funding. The
city picked up the tab. Thats the issue, said Dunkerley, who
is now a city council member.

The city looked to Seton, Austins only other nonprofit provider,
for help.

Seton has obligations as a Catholic facility and we respect
those, Dunkerley said. What we were trying to do was let Seton
remain Catholic and let us do the things we need to do in dealing with a public
hospital.

From June 2001 to February 2002, the toughest negotiations concerned
emergency contraception: medication given within 72 hours of intercourse to
prevent pregnancy. Seton agreed to provide it only to women who reported
theyd been sexually assaulted and who tested negative for ovulation.

Community advocates wanted Brackenridge to provide the medication to
women who requested it, with or without a police report or test. Seton and the
city finally agreed that women requesting emergency contraception without
claiming sexual assault would be referred to a city clinic.

A parent looks on as a nurse takes his
newborn baby's footprints at Brackenridge Hospital in Austin, Texas.-- Marc Swendner/Seton Healthcare
Network

Romberg, CEO of the Womens Health and Family Planning Association
of Texas, called the emergency contraception agreement a huge loss
because close to 90 percent of sexual assaults go unreported. As to
the ovulation test, she said, At the time when [a woman] most needs
[emergency contraception], were not going to give it to her.

Nobody but the Catholic church calls it an abortifacient,
said Romberg, an Episcopalian. When the Catholic church itself cannot
convince its own parishioners to obey the churchs position on family
planning and contraceptives and abortion, it is just outrageous that they would
try and impose this on the general public.

The 2002 agreement calls for Seton to continue obstetrical and
gynecological services on Brackenridges second floor while women
requesting tubal ligation (defined as sterilization in the Catholic directives)
or emergency contraception will go to the citys fifth-floor
hospital-within-a-hospital or a city clinic.

Romberg argued that tubal ligation is the most widely used
contraceptive, especially among low-income women, and is approved by the
American College of Obstetricians and Gynecologists as safe and effective.
Tubal ligation is the answer for many women whove completed their
childbearing and is most appropriately done immediately following delivery,
Romberg said, adding that these women should not be segregated in
the hospital-within-a-hospital. She added that the fifth-floor facility will
perform a limited number of tubal ligations despite the areas growing
population, potentially denying service to poor women.

According to Romberg, The city feared the hospital would go back
to them; they considered it a financially losing proposition. In fact, Seton,
in 1999 and 2000, made money managing that hospital. Theres no reason why
the city couldnt have.

Kissling of Catholics for a Free Choice said Brackenridge failed because
Medicaid and Medicare reimbursements were too low for the city to sustain it, a
government failure to meet its obligations. If we were talking about a
school district and the city said, We dont have enough money to
operate our public school so were going to turn it over to the Catholic
church, nobody would think that was an appropriate solution, she
said. Why do we think its an appropriate solution for health care
to turn it over to a religious institution?

Glenda Parks, executive director of Planned Parenthood of the Texas
Capital Region, called for more financial disclosure from Seton: We have
their report that says theyve paid for so much charity care. But how much
money are they losing? I really dont know the financial condition of
Brackenridge and whether or not it makes or loses money, and to my knowledge no
one knows, said Parks, who was appointed a director for the
hospital-within-a-hospital. That is all considered proprietary
information, which Seton does not disclose.

According to Hayes, who was temporarily Seton Healthcare Network CEO
during negotiations, the network is able to run Brackenridge profitably because
of philanthropy and its size. Its very hard for a stand-alone
public hospital to take all the charity care, said Hayes, now executive
vice president and chief operating officer. Its easier to absorb
that across a system. In addition, as a not-for-profit, Seton returns
gains to the operation.

When the city first approached Seton about Brackenridge, Hays says,
Seton felt it was exactly in line with the reason we had been founded by
the Daughters of Charity.

To comply with the 2001 directives, Seton worked closely with Austin
Bishop Gregory Aymond and the National Bioethics Center, she said, just as
Seton consulted Catholic ethicists for approval of the original lease.

Hayes said that in the fiscal year ending June 30, 2001, Brackenridge
charity care, narrowly defined as Setons cost for clinic care
plus write-offs, was around $37 million.

Add $14.5 million in unreimbursed Medicaid, $43 million unreimbursed
Medicare and $9 million of what Seton calls community benefit --
immunization drives and health education -- and you have $103.5 million, Hayes
said. And that does not count bad debt.

Hayes said she found the negotiations challenging,
particularly the criticisms from spokespersons for sexual rights
activists. I respect the fact that they were speaking their conscience and
speaking it with energy, she said, adding some activists expressed
appreciation for Setons indigent care and need to follow its own
conscience.

Neither conservative Catholics nor the activists are likely happy with
the solution, Hayes said, but Seton has been straightforward from the start
about what it could and could not do at Brackenridge.

People talk about the directives as if its a book about
sterilization. Its a book about the ministry of Jesus in health
care, Hayes noted. For me, the Seton Healthcare Network in Austin
has taken that very seriously and has worked through some uncomfortable things
to try to follow that mission.

The word from Rome is that the Congregation for the Doctrine of the
Faith accepted the Austin arrangement as a way to deal with an existing and
problematic situation, but not as a model for future arrangements.

A report on the Catholic Health Association annual meeting June 8-11
is available on the NCR Web site,NCRonline.org

Suzanne Batchelor is a freelance writer on national health care
issues.